Care Transformation Center Blog

Your top population health questions from Q1, answered

by Darby Sullivan, Samara Ford, and Tomi Ogundimu

Across the first quarter of 2019, we received over 200 questions from members through The Expert Center on all aspects of care transformation. In 2018, many of our questions focused on how best to optimize the foundational aspects of population health, from care transitions to palliative care. This year, your peers are increasingly interested in how to effectively manage specialized populations like dual-eligible patients and pediatric behavioral health needs.

1. How can we best care for the complex needs of dual eligible patients?

Patients eligible for both Medicare and Medicaid coverage typically have very high acuity levels and a broad scope of needs. With a greater likelihood of psychosocial care gaps and complex chronic conditions, dual eligibles often drive elevated cost and utilization.

Providers who well-manage dual eligible patients invest in care management strategies that surface and solve their social care gaps, streamline inpatient care through programs like Acute Care for the Elderly (ACE), and wrap around longitudinal support with ancillary services (e.g., medication management therapy). We reviewed the evidence base behind interventions to select those that affect key performance indicators (KPIs) for high-risk patients, including cost, utilization, quality and clinical outcomes, access, and stakeholder satisfaction. Based on that analysis, dual eligibles benefit from the following investments that help curb readmissions, avoidable utilization, and the total cost of care:

  • High-risk care management (high strength of evidence);
  • Palliative care (medium strength of evidence);
  • Super-utilizer clinics (medium strength of evidence);
  • Supportive housing programs (medium strength of evidence);
  • Community health worker support (medium strength of evidence); and
  • Non-emergency transportation services (low strength of evidence).

Learn more about the evidence behind 25 of the most popular population health interventions

However, population health investments are only effective if patients are truly engaged in their own care. As with all populations, standardize intake assessments to identify patients' activation levels and tailor their psychosocial care plans according to their readiness. Patients who are less activated may benefit from additional engagement tactics, such as teach-back, motivational interviewing, and shared decision making.

2. How can we meet the behavioral health needs of pediatric patients using telehealth innovations?

The behavioral health care shortage is even more acute for pediatric patients. Forty-one states are defined as severe shortage areas (1-to-17 child and adolescent psychiatrists per 100,000 patients), while around 15 million patients need behavioral health care. To address this gap and extend care, provider organizations are investing in three common telehealth strategies:

  1. Offer real-time virtual visits in a hub-and-spoke model

    Mercy, a health system based in Chesterfield, Missouri, launched Mercy Virtual, a centralized hub for virtual care operating 24 hours a day. Though Mercy Virtual, patients access secure virtual visits with mental health specialists from their pediatrician's office. The program, vMentalWellness Kids, also includes training for pediatricians, pediatric subspecialists, and family medicine doctors to strengthen their skills in diagnosing ADHD, depression, anxiety, and oppositional defiant disorder. After one year in operation, Mercy has trained 250 staff and cared for more than 1,200 patients.

  2. Train primary care team members to screen for common childhood mental illnesses

    Children's Hospital in Omaha deployed the popular tele-mentoring model, Project ECHO, to create teleECHO clinics. Experts offer education to all primary care team members (including PCPs, PAs, NPs, RNs, SWs, and mental health practitioners) during virtual sessions on different aspects of child mental and behavioral health. Each session is only 15 to 20 minutes to fit into the busy schedules of the team. Trainings include information on screening and evaluation, referral practices, and office-based interventions.

  3. Partner with school districts to identify at-risk patients

    Children's Health in Dallas, Texas, launched a school-based program with local districts to improve identification and care of patients with behavioral health challenges. The program trains teachers, counselors, and coaches on how to identify students who might benefit from therapy video visits. Once connected with programming, students take part in 30-minute televisits with a licensed behavioral health clinician in a private room at the school. Patients with more acute needs are referred to an in-person behavioral health professional for long-term support. After two years, the program has served 21,000 patients across 22 campuses, including 400 virtual therapy sessions.

Care Management 101

As hospitals face increasing pressure to care for complex patient populations, developing a care management strategy that goes beyond the hospital walls isn't optional—it's a necessity.

Join our webconference on May 29 to learn five key attributes of effective care management organizations—regardless of what care model your organization has invested in.

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